Ethics of Resuscitation at Different Stages of Life: A Survey of Perinatal Physicians (original) (raw)
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Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstétrique et gynécologie du Canada : JOGC, 2011
Across Canada, the rate of preterm birth (i.e., at < 37 weeks' gestation) has been steadily increasing. Advances in perinatal medicine and neonatal intensive care have resulted in an increased capacity to intervene at the extremes of prematurity, leading to an increase in the overall survival of infants born at early gestations. There has been little corresponding decrease in long-term complications. As a result, additional stresses are placed on neonatal intensive care units across the country, impacting families, health care professionals, and society as a whole. Moral distress and moral residue are often cited in the neonatal-perinatal literature as stressors experienced by those who participate in the resuscitation decision-making process. They are directly related to the challenge of making a concrete decision about life and death at extremely early gestations in the context of long-term uncertainty. In this review, we performed a systematic search of medical and ethics ...
BMC Medical Ethics
Background Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs. Methods We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven. Results The main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Pa...
The ethics of delivery-room resuscitation
Seminars in Fetal and Neonatal Medicine, 2008
Perinatal care continues to improve and the number of extremely preterm babies delivered increases. What is the outcome for those babies? Under what circumstances should we not initiate resuscitation or under what circumstances should we discontinue support? How accurate and predictive are the data we have and how can these be improved? Who should make the decisions and how should they be made? Should we follow different guidelines in different settings? The following narrative will examine some of these questions but cannot answer them all. ª
PEDIATRICS, 2006
OBJECTIVES. The objective of this study was to determine the attitudes of a variety of health care providers toward the recommendations that should be made to parents regarding the resuscitation of infants who are born at the margins of viability. METHODS. A written questionnaire was distributed to the medical and nursing staff at 4 tertiary perinatal centers. For each of 5 weekly gestational age intervals from 22 weeks to 26 weeks, 6 days, the health care providers were asked to describe on a scale from 1 to 5 whether they would strongly discourage through strongly encourage resuscitation. They also were queried regarding their comfort with counseling regarding these issues. The attitudes of various groups of providers were compared across weekly intervals. RESULTS. A total of 204 physicians and 539 nurses completed the survey. The majority would strongly discourage, either discourage or strongly discourage, be neutral or recommend, recommend or strongly recommend, and strongly rec...
Provider Perspectives Regarding Resuscitation Decisions for Neonates and Other Vulnerable Patients
The Journal of Pediatrics, 2017
Objectives To use structured surveys to assess the perspectives of pediatric residents and neonatal nurses on resuscitation decisions for vulnerable patients, including neonates. Study design Pediatric providers were surveyed using scenarios for 6 critically ill patients of different ages with outcomes explicitly described. Providers were asked (1) whether resuscitation was in each patient's best interest; (2) whether they would accept families' wishes for comfort care (no resuscitation); and (3) to rank patients in order of priority for resuscitation. In a structured interview, each participant explained how they evaluated patient interests and when applicable, why their answers differed for neonates. Interviews were audiotaped; transcripts were analyzed using thematic analysis and mixed methods. Results Eighty pediatric residents and neonatal nurses participated (response rate 74%). When making life and death decisions, participants considered (1) patient characteristics (96%), (2) personal experience/biases (85%), (3) family's wishes and desires (81%), (4) disease characteristics (74%), and (5) societal perspectives (36%). These factors were not in favor of sick neonates: of the participants, 85% reported having negative biases toward neonates and 60% did not read, misinterpreted, and/or distrusted neonatal outcome statistics. Additional factors used to justify comfort care for neonates included limited personhood and lack of relationships/attachment (73%); prioritization of family's best interest, and social acceptability of death (36%). When these preconceptions were discussed, 70% of respondents reported they would change their answers in favor of neonates. Conclusions Resuscitation decisions for neonates are based on many factors, such as considerations of personhood and family's interests (that are not traditional indicators of benefit), which may explain why decision making is different for the neonatal population. (J Pediatr 2017;■■:■■-■■). See editorial, p ••• T he majority of pediatric deaths occur in intensive care units, 1,2 most often after a decision to limit life-support. 3-7 These decisions, made by parents and providers, are among the hardest decisions in pediatrics. Evaluating the interest of children is complex. 8,9 Some authors invoke their best interests, 10 others "good enough" or "not unreasonable" interests, 11 and for others, avoiding harm is the main goal. 12 When an intervention is in the interest of a child and nonintervention places a child at significant harm, the intervention is generally considered as being legally and ethically preferable. Empirical investigations have demonstrated that neonates are treated differently when life and death decisions are made. 13-25 In questionnaire studies, scenarios of critically ill incompetent patients of different ages were presented with outcomes explicitly described. Although many respondents evaluated that resuscitation was in the interest of neonates, a larger proportion estimated that resuscitation was in the interest of older patients with similar or worse outcomes. 14-22 For older patients, a family's request for comfort care was rarely accepted when respondents evaluated resuscitation to be in a patient's interest. On the other hand, comfort care was generally accepted for neonates, despite estimating that resuscitation was in their interest. 14-22 This differential treatment seems to transcend culture and has been demonstrated in 7 culturally different countries, 18 in a large nonmedical population, 14 among pediatricians who do not work in neonatology 16 and among physicians who do not work in pediatrics. 20 In none of these studies were participants asked to explain their answers. The goal of this study was to investigate how providers evaluate the interests of vulnerable patients and why their decision making differs for neonates. Methods A mixed methods sequential explanatory design was used. First, participants answered a questionnaire that has been validated, widely used, and systematically NICU Neonatal intensive care unit
Decisions concerning resuscitation and end-of-life care in neonates. Bioethical aspects (Part I)
Archivos Argentinos De Pediatria, 2022
Coping with the death of a newborn infant requires training and reflection regarding the end-of-life decision-making process, communication with the family, and the care to be provided. The objective of this article is to analyze in depth the salient aspects of neonatal bioethics applied to end-of-life situations in newborn infants. Part I describes notions of therapeutic futility, redirection of care criteria, patient and family rights, and concepts about the value of life. Part II analyzes situations that deserve considering the redirection of care and delves into aspects of communication and the complex process of end-of-life decision-making in newborn infants.